Follow-up·February 27, 2025

On 2/27/25 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met with Cheif Executive Officer (CEO), Roberta "Ro" Linscheid and Licensed Vocational Nurse (LVN), Cecilia Barraza was informed Administrator, Virginia Penner was unavailable. LPA introduced self, explained reason for visit and was permitted entry into the facility. This Case Management is being conducted as follow up for Incident Reports (IR) received by the Department. 1) IR was received by CCL for an incident occurring on 8/31/2024. R1 fell and was sent to Emergency Room. R1 was given a diagnosis of a pelvic fracture. Facility did not report this incident to CCL until 9/14/24. Deficiency cited for late reporting per Title 22. 2) IR received by CCL for incident on 10/26/24. R2 had physical altercation with R3 and R4. PD called to the facility. SOC 341 was completed but not submitted to CCL. Deficiency cited for reporting requirements per Title 22. 3) IR received by CCL for incident occurring on 12/30/24. R5 fell in dining room, hitting their shoulder and falling on wrist. R5 was sent to the hospital and was diagnosed with a fracture to their left wrist. Facility did not provide discharge paperwork showing follow up for R5. During record review of discharge paperwork, R5 returned to the physician on 1/1/25 and 1/10/25 for follow up on this injury. R5 wore brace with no further follow up. No deficiencies cited for this incident. 4) IR received by CCL for incident occurring on 2/11/25. R6 was found outside at 5:15 am. Per S1 there was a freeze warning the night of 2/10/25. Per incident report R6 was found outside memory care unit in the patio area with bleeding to their head. R6 was moving but not responsive to conversation. R6 sent to ER via EMS and treated for low blood pressure, hypothermia and head injury. Additional information need for this case management. LPA will return once gathered. Deficiencies will be issued at that time, if necessary. CONT... CONT... 5) During annual visit conducted on 2/27/25 R7 was observed with bruising to the left side of the face. R7 stated they fell. Record review of R7's file disclosed incident occurred on 2/22/25. R7 was sent to ER and returned with diagnosis of UTI. No deficiency cited for this incident. Deficiencies cited per Title 22. Exit interview completed with LVN, Cecilia Barraza. A copy of this report, deficiencies and appeal rights provided.